Form Phq-9 - Patient Health Questionnaire Modified For Teens (Page 3 of 3) in pdf

A Survey From Your Healthcare Provider —

PHQ-9 Modified for Teens

Name ______________________________________________________________________ Clinician _______________________________________________

Medical Record or ID Number _______________________________________________ Date ____________________________________________________

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks?

For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.

(0)

(1)

(2)

(3)

Not At

Several

More Than

Nearly

All

Days

Half the Days

Every Day

1. Feeling down, depressed, irritable, or hopeless?

2. Little interest or pleasure in doing things?

3. Trouble falling asleep, staying asleep, or sleeping too much?

4. Poor appetite, weight loss, or overeating?

5. Feeling tired, or having little energy?

6. Feeling bad about yourself — or feeling that you are a failure, or

that you have let yourself or your family down?

7. Trouble concentrating on things like school work, reading,

or watching TV?

8. Moving or speaking so slowly that other people could have

noticed?

Or the opposite — being so fidgety or restless that

you were moving around a lot more than usual?

9. Thoughts that you would be better off dead, or of hurting

yourself in some way?

10. In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

Yes

11. If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work,

take care of things at home or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

12. Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes

13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?

Yes

Score _____________________

FOR OFFICE USE ONLY

Used with Permission of the GLAD-PC Steering Group:

Source: Patient Health Questionnaire Modified for Teens (PHQ-9) (Author: Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues)

Form Phq-9 - Patient Health Questionnaire Modified For Teens Page 3

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